Tag Archives: Intactivism

Advocating for personal choice (also known as autonomy) with regard to elective genital surgeries. The following are examples of unnecessary genital surgeries that are usually performed without the consent of the person receiving it: female circumcision (female genital mutilation), infant male circumcision (male genital mutilation) and “cosmetic” genital surgeries for infants and children with intersex/DSD conditions.

Kickstarter film: “American Secret: The Circumcision Agenda”

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“American Secret” examines the history behind popularizing male infant circumcision in the United States and the economic and cultural incentives responsible for its continued practice. The film pushes back against this rarely questioned cultural norm, which, though ingrained domestically has long since fallen out of favor abroad.

On the face of it, “American Secret” is about circumcision. At core the film is an examination of how memes proliferate, how ideas spread, and how thought patterns take hold. The film also explores questions we rarely ask ourselves, such as how we decide what we’re going to think about, what we’re going to reconsider, what we’re going to resist, and what we aren’t. The film’s overarching questions being: “How do we come to believe what we believe?” and “What role do reason and fact play in establishing or changing our beliefs?”

We do NOT want to cut your beautiful baby boy!

IMG_5505Dear Dr Pate,

I’m a third-year medical student who is strongly considering going into OBGYN. Unfortunately, I’ve been really dismayed to discover how common it is for OBGYN residency programs to require their residents to perform circumcisions. I’ve begun to worry that my moral opposition to circumcision might be incompatible with going into OBGYN. I don’t want to get into a situation where I might be fired if I don’t perform circumcisions because I would rather get fired–and if that’s the case then why go into that field in the first place. I started to google about the topic and your blog was one of the first to come up.

Do you have any advice for a student in my situation? Should I try to seek out OBGYN residency programs that don’t require residents to circumcise? Should I just match into OBGYN and then refuse once I already have the job (can I be fired for that?).

Thanks,
MS3


Dear MS3,

Thanks for writing! I find it so refreshing to hear more and more from students, such as yourself, who desire to refrain from performing circumcision. Clearly you are not alone but tradition is deeply engrained in culture and deviation therefrom is considered illogical and threatening. If you are interested in OB/GYN, don’t worry about circumcisions. I wouldn’t even bother mentioning it in your interviews — it falls under the same legal protection as beliefs about abortion.

I encourage you to check out my post — Do medical students have to assist circumcisions? There are links to resources available to you. Hold you head high! Where there is a will there is a way. You don’t have to compromise yourself.

Some will tell you that refraining will limit your career opportunities. It is true that some jobs will try to push you. You can take either approach — put it out there so that potential problems will fall away before you become too invested or discuss it after the fact and assert your rights.

I chose to be proud and loud throughout my process; I stirred controversy and rocked the boat. This did result in expected consequences and more than a few blows to my ego however it was the right path for me. At least one attending physician and another resident refuse to do circumcisions because of my example. And that, for me, made the pain and suffering worth it.

And I have not been pushed aside by all employers as I was warned. One recruiter even told me that I didn’t have a chance landing a job in a major city. I dropped him like a rock. Instead I have joined a phenomenal group practice in a very coveted location just 20 minutes north of Manhattan.

So my advice to you is this: Follow the path that feels right for you and do not fear the obstacles that you will find. Be true to yourself and work hard and your path will continue to unfold before you. Keep your eyes on that path and drop the rocks!

Sincerely,
James Pate, MD
http://JamesPateMD.com

Care of the prematurely retracted foreskin

Dear Dr Pate,

I’ve read some of your (awesome) posts and have a random question I’m hoping you can answer! :) I know of a mom whose son was forcibly retracted when he was 7 months old. Unfortunately, she was told that after that point, she needed to continue doing it, which she did for another year following that incident. Now she knows that was wrong. The problem is that he’s fully retractible now (even though not “naturally” so), and she doesn’t know if she should continue asking him to retract himself to clean it (as she would a naturally retractible child), or not. He’s only 2 years old, and resistant to doing so. I’m inclined to say leave it alone and that just soaking in the bath will be good enough, but wanted to double-check. If he doesn’t retract to clean, would it encourage adhesions or infection?


Dear KD,

Thank you for your kind comments and your excellent question! I am inclined to tell her to leave it alone as well given that kiddos do not have the same amount of body secretions as teens and adults. Likewise, I can’t image that other cultures around the world pay even a 10th of the interest in either the excision or maintenance of the foreskin as we do in the U.S. Do little girls really need to be taught anything more to wash briefly in the tub? The same should apply to little boys. However, I am not a pediatrician so I asked my colleagues for their opinions which follow below. Best of luck to the little tyke and thanks again for writing.

Sincerely,

James Pate, MD
http://jamespatemd.com


I agree with you and would have advised the same. If he is resistant to retraction, I would leave it alone. It may re-adhere, but I would imagine that it will detach over time without undue intervention despite the earlier forcible retraction. If not, he can use steroid cream if indicated. I don’t see it becoming infected.

On the other hand he may become more amenable to retraction and cleaning in the coming months which would make it a non-issue. He may be objecting because he’s two years old. But I see no reason to compel him to do something he doesn’t want to do at this time.
―Dr Paula Brinkley, pediatrician


I just wanted to assure you that your advice was just right! We need not retract the eyelid to wash under it, and mucous membrane will keep adjacent tissues from adhering one to the other. In most non-circumcising countries, from what men have told me, they often are taught little and generally figure out hygiene on their own. If they are told something, it’s usually around puberty, probably when secondary sex hormones are produced.

We don’t teach girls to pull their prepuce back to wash under it and we don’t put Q-tips or anything else into their vaginas to wash them. The body is self-cleaning. And, little boys need a normal sense of unconcerned boyhood. The baby’s objections to having his foreskin messed with is the message to which everyone should listen.

There are three great articles that you might find helpful at http://www.nocirc.org/articles. They are:

―Marilyn Milos, RN, Executive Director, National Organization of Circumcision Information Resource Centers (NOCIRC)


In my opinion, you don’t have to be a pediatrician to answer this question – most pediatricians don’t know anything about taking care of the foreskin anyway! – so I’m going to offer my own take on this.

There are no controlled studies on correct care of the intact penis, so the best we have to go on is a good understanding of the structure and development of the foreskin, plus common sense.

The few studies that I know of that looked at retractability, foreskin hygiene, and outcomes are so methodologically problematic and ignorant of the natural development of the foreskin as to be completely worthless guides (Kalcev 1964, Krueger and Osborn, 1986).

Most of the “literature” on care of the intact penis are merely opinion pieces. One would hope that this “opinion” would be based on a solid knowledge of the development of the intact penis, and/or extensive experience in conservative care of the intact penis, but unfortunately this is not the case, as we all know, and there is a lot of mistaken and potentially harmful advice given.

“I did an inservice on care of the intact penis 6+ years ago where I dug up as much literature on it as I could (17 articles, 2 of which were from CIRP and NOCIRC). I am attaching a summary of some of the advice from these handouts that I posted at Mothering.com some years back, plus some additional quotes that support the idea of “leave it alone”.

Here’s the general consensus from these handouts:

  • If the FS is non-retractable, no matter how old the boy is, all that need be done is to wash off the outside. PERIOD.
  • Once the FS is retractable AND the boy is developmentally able (generally have the motor dexterity and ability to follow instructions by about age 4-5), he can be taught to retract, rinse, replace. [Note, this makes the idea of requesting a 2 year old to retract and clean himself seem pretty pointless.]

Sources that specifically mention frequency suggest:

  • In childhood: this rinsing might be done say only “occasionally”
  • By puberty: more “regular”, or “daily” rinsing is suggested

Although some older articles will recommend that parents retract the child (based, I believe on a preconception of the foreskin as problematic, and ignorance of the natural development of the intact penis), most do NOT say this, and a number do support the idea of leaving it alone (see my Mothering post attachment). In fact there is one great quote from Canadian pediatric urologist Peter Anderson stating that “there’s no evidence there’s any need to clean under the foreskin before puberty.”

Remember that the foreskin is designed to keep the ooky stuff out (tight outlet in childhood, sphincter-like action of the peripenic muscle), and that it is flushed outward multiple times a day with sterile urine, thus keeping itself clean.

As a John Geisheker likes to point out, “Our primate predecessors were unlikely to head down to a nearby river every day to scrub their children’s genitals. Nature would quickly eliminate those who needed such care. Only those tough enough to not require genital cleansing would have survived. We are those survivors. … Mid-19th century English-speaking boys and girls did not suddenly require aggressive genital hygiene when their ancestors, for hundreds of generations, survived nicely on benign neglect.”

If this 2-year-old is resistant to having his foreskin retracted, by all means, leave it alone! It is unnecessary from a hygiene point of view, and could be more psychologically distressing than its worth. He will discover the joys of retracting himself when he’s ready and interested himself. In the meantime, it is quite possible that just playing with his penis in clean tub water might be all the cleaning needed. Since the average age to full retractability is somewhere are age 10, I would encourage this young mom to sit back, respect her son’s own time table and emotional boundaries, and just let nature take its course.

―Gillian Longley RN, BSN, MSS, Colorado NOCIRC


Rather than re-invent the wheel and write a longish, potentially unwelcome, or over-obvious email, I am attaching several articles we at DOC wrote for Psychology Today magazine on this very issue.

The short answer, (which I suspect you know instinctively), is that urine is sterile and the boy-child is ‘washed’ at each urination. The notion that intact (not C’d) boys need special hygiene is an invented one of Anglophone origin, its sources easily traced to the mid 19th century, a time of great anxiety about masturbation (even among toddlers) as a source of disease. This was before Koch (1879) and others identified pathogens.

In evolutionary terms, the notion that boys need special genital hygiene makes no sense. Our primate ancestors were likely far more concerned with foraging for food and finding a safe place to sleep each night. There was no time or motive to scrub the genitalia of their offspring (and my primatologist neighbor tells me no such behavior has ever been seen in the wild).

We are their descendants who never needed any such care. The infant vulva and infant penis, like the infant eyes and mouth, are self-defending and self-cleaning. It could hardly be otherwise.

―John V. Geisheker, J.D., LL.M. Executive Director, General Counsel, Doctors Opposing Circumcision (D.O.C.)

Contrary to marketing in Africa, circumcision does NOT prevent HIV transmission and may increase it

Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns. Journal of Law & Medicine. 19(2):316-34, 2011 Dec.
Abstract
“In 2007, WHO/UNAIDS recommended male circumcision as an HIV-preventive measure based on three sub-Saharan African randomised clinical trials (RCTs) into female-to-male sexual transmission. A related RCT investigated male-to-female transmission. However, the trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV-positive than in those where more circumcised men were HIV-positive? Why were men sampled from specific ethnic subgroups? Why were so many participants lost to follow-up? Why did men in the male circumcision groups receive additional counselling on safe sex practices? While the absolute reduction in HIV transmission associated with male circumcision across the three female-to-male trials was only about 1.3%, relative reduction was reported as 60%, but, after correction for lead-time bias, averaged 49%. In the Kenyan trial, male circumcision appears to have been associated with four new incident infections. In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain.”

If the WHO/UNAIDS really wants to turn the epidemic tide, distribute free condoms!

Is it lawful to use Medicaid to pay for circumcision? NO!

Is it lawful to use Medicaid to pay for circumcision?.
Journal of Law & Medicine. 19(2):335-53, 2011 Dec.

Abstract
“Since 1965, tens of millions of boys have been circumcised under the Medicaid program, most at birth, at a cost to the United States Federal Government, the States and taxpayers of billions of dollars. Although 18 States have ended coverage since 1982, the United States Government and 32 States continue to pay for non-therapeutic circumcision, even though no medical association in the world recommends it. Many cite American medical association policy that the procedure has potential medical benefits as well as disadvantages, and that the circumcision decision should be left to parents. This article shows that Medicaid coverage of circumcision is not a policy issue because it is prohibited by federal and State law. As American medical associations concede, non-therapeutic circumcision is unnecessary, elective, cosmetic surgery on healthy boys, usually performed for cultural, personal or religious reasons. The fundamental principle of Medicaid law is that Medicaid only covers necessary medical treatments after the diagnosis of a current medical condition. Physicians and hospitals face severe penalties for charging Medicaid for circumcisions. Medicaid officials and the Federal and State Governments are also required to end coverage. It is unlawful to circumcise and to allow the circumcision of healthy boys at the expense of the government and taxpayers.”

Don’t waste taxpayer dollars on destructive “cosmetic” procedures on un-consented infant boys!

Do medical students have to assist circumcisions?

Dear Dr Pate,

I am a 2nd year medical student that will be starting rotations soon. Coming across your website, I noticed you were an intactivist OB/Gyn. I am also an intactivist and realize there will be many procirc doctors with crazy mindsets. It is expected that there will be issues with doctors when I refuse to help with this operation.

Do you have any advice for me at this point?
Do you get a lot of resistance to your views and how do you deal with it?

I read through your blog briefly, there are some interesting things contained there. Thank You!


Dear P,

Thanks for writing! You absolutely have the right to refuse to participate in any way of the circumcision process including offering the procedure to new parents when you round on patients, discussing it with interested parents who bring up the topic, consenting parents for the procedure, observing and performing circumcisions. Check out the pamphlet Conscientious Objection to the Performance of Non-therapeutic Circumcision of Children: A guidance for healthcare providers from Doctors Opposing Circumcision. You will likely get some flack, but it is absolutely worth it. I have blogged quite a bit about experiences with my residency program regarding the subject. Senior residents in particular were not happy with my stance given that they then “had to do my work”. Whatever. No one can make you do anything you are morally opposed to. Check out the links on my website for information about intactivist organizations. There are a LOT of resources for you and for the parents you will come in contact with. Thanks for your willingness to stand up for personal autonomy and “do no harm.” Feel free to write again at anytime. Good luck!

Sincerely,

James Pate, MD
http://jamespatemd.com

Considering circumcision?

Circumcision has been a “traditional” procedure in the U.S. for many decades. However, more and more parents are choosing to leave their sons intact in spite of  a great deal of pressure from other family members and/or religious leaders to follow their traditions. Why do these parents refuse? What’s the big deal?

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Well I could tell you, “Go ahead! It’s just a little skin,” and pad my wallet with the extra money I could make from these “simple” procedures. Or I can speak to you as a father who regrets his decision to have his son circumcised and try to provide you with the information you should know before making this life-altering decision for your son(s).

I have written multiple posts on this subject and am what is known as an “intactivist” — an activist for the preservation of intact genitalia for all minors unless medical necessity (not preference) dictates otherwise. However, that is not the point of this post. I simply desire to give you information so that your decision, whichever it may be, may be fully informed.

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If you are interested in finding out more about circumcision I highly recommend the following resources:

Finally, if you are just nervous about how to care for an intact penis, it’s much easier than you think. Check out the following pamphlets on how to care for your infant son and what to expect as he ages.

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A Public Apology to My Circumcised Son

A Public Apology to My Circumcised Son is another post I came across while catching up on my break. It was posted 11/21/10 on Peachy Keen Birth Services.

“My Little Buster,” the distraught mother writes, “I’m so sorry. How else do I begin this?… As a parent, there will be a million things you will look back on and think ‘Gee… I wish I would have done that differently…’… But how in the hell do I apologize for having part of your genitals amputated for NO MEDICAL REASON? When you were less than 24 hours old!… So for all of the parenting moments I look back upon, wishing I could re-do, having you circumcised is the only one I have utter remorse for. With much, much love, Your Mommy.”

The post struck a cord in me because I too carry this burden, and I echo the sentiments of this mother.

When my son was born in 1998 — in my former life as a closeted, gay, married, mechanical engineer — my ex-wife and I had little discussion on the matter. I am circumcised, my father is circumcised and her father and brother are circumcised. Why wouldn’t we do to our son what was a norm for our family? We didn’t understand the risks. We didn’t understand the permanent damage that we were condoning. We did not understand the history of circumcision in the U.S. nor its root in puritanical aims to deter masturbation. We were simply uninformed and did not understand the gravity of our decision to circumcise our son.

Now it is too late. We stole that choice from him and his body is permanently altered. I have apologized to him. The tears ran down my cheeks. He has forgiven me but at his young age he cannot comprehend the consequences of that decision. Do not repeat our mistakes. Leave your sons whole as nature/god intended them to be. Allow them the autonomy over their bodies that is rightfully theirs alone. Let’s end this barbaric custom of infant genital mutilation!

– James Pate, MD

The Genocide of Intersex People

 

American Grotesque posted The Genocide of Intersex People on 11/28/11. I recently came across it while catching up on twitter and facebook during my holiday break (a true luxury for a resident!). In this post the author discusses the damage perpetuated by the myth of binary gender, its social construction and legal ramification. The author places hir-self in the place of “patients” whose bodies defy the myth and without consent are reconstructed to appear to confirm it. Yet in spite of appearances they remain outside of the binary and their shame and scars and are shrouded in secrecy and silence. Is this moral? Is this fair? Is this just?

“Our lives begin to end the day we become silent about things that matter. [And] In the end, we will remember not the words of our enemies, but the silence of our friends.” ―Martin Luther King Jr

CIRCUMCISION: Another Baby Dies

Joseph for Genital Integrity reports in his blog entry, CIRCUMCISION: Another Baby Dies, that “Connor James was born on Thanksgiving Weekend, Friday, November 25th in Pittsburg, PA. On Saturday, November 26th, Baby Connor bled to death following his circumcision. Circumcision claims yet another life.” He goes on to discuss other baby boys that have died in the US as a result of this barbaric practice and mourns their loss. Peace to the boys and their families. Shame on the medical community!

[NOTE: A reader notified me on 2/15/12 that she lives in Pittsburg and has been unable to substantiate this claim. It is possible that Connor James is urban legend however there  many other cases that have been verified and published by reputable sources; A Young Life Passes, and a Ritual of Birth Begins published by the New York Times is one example of many. The International Coalition for Genital Integrity estimates that around 100 male infants die in the US each year due to circumcision complications. Infant male circumcision is an awful procedure and an unacceptable contributor to infant mortality.]